ORIGINAL

Maternal knowledge about childcare during the COVID-19 pandemic: a qualitative approach

Mayane Cândido da Silva Leite Cardoso1, Gracielly Beatriz Cardoso de Oliveira1, Ana Márcia Nóbrega Dantas2, Gabriela Lisieux Lima Gomes2

1 João Pessoa University Center, PB, Brazil

2 Federal University of Paraíba, PB, Brazil

ABSTRACT

Objective: to describe maternal knowledge about childcare during the COVID-19 pandemic. Method: descriptive field research with a qualitative approach, carried out with 30 mothers of young children aged between zero and 24 months. Participants were selected at home, due to the COVID-19 pandemic. Data were analyzed and interpreted through content analysis. Results: 4 categories were created: Mothers' knowledge about childcare; Childcare appointments in times of the COVID-19 pandemic; Surveillance of child development from the perspective of mothers; Mothers' knowledge about the assessment of infant developmental milestones. Conclusion: poor communication between health providers and mothers, limited knowledge of mothers in relation to child development and because of the pandemic were revealed, and mothers are afraid to take children for child developmental follow-up.

Keywords: Children Development; Primary Health Care; Nursing.

INTRODUCTION

The Family Health Strategy (FHS) promotes the connection of evidence-based behaviors with the community, through childcare, enabling nurses to be able to assist children in the promotion and detection of possible risk factors(1).

Nurses are able to provide comprehensive care to the child so that he/she exercises verbal and non-verbal communication(2), in addition to providing the Systematization of Nursing Care (SNC) and operating the Nursing Process (NP) during childcare.

Nursing appointments, carried out in childcare, provides a link between the health provider and the child-family/caregiver binomial in order to encourage them to have appointments, in addition to providing guidance on child developmental stimuli at home(3).

Child development in the first years of life is marked by bonding and neural stimuli of the brain(4). Therefore, they are influenced by social, cognitive and affective factors with the aim of reaching their potential. However, when there are instabilities in those influences, the risk of development deficit increases(5).

Achieving child development potential has to do with the acquisition of children's skills for academic, social, economic, behavioral life and emotional balance(6). In this sense, the family, and especially the mother, plays a key role in laying a foundation, helping with specific stimuli in the development process(5).

Child development is a public health issue, since thousands of children are at risk of not reaching the developmental milestones for each age, especially those under five, due to the maturation process(4) and vulnerability. A study shows that the rate of children who do not reach their potential is still high and the lack of care and guidance regarding the importance of intervening in a timely manner is also worrisome(6).

The mother's understanding of childcare guidelines is essential for her to assume responsibility, to value and take the child to nursing appointments. However, maternal perception is based on each one's culture, and this can be both beneficial and harmful for the child's development.

In addition, childcare is challenging for health providers and mothers in the COVID-19 pandemic, given that social distancing and isolation are making it difficult for mothers to access health facilities and they are often encouraged to take care of the child at home(7). However, taking the children to an appointment only in case of illness is against the guidelines of health promotion. Social media have a direct influence on this aspect, and many mothers resist taking their children to health units and do not attend the appointments because they are afraid and want to protect the child.

Health services in Primary Health Care (PHC) during the pandemic, despite being considered an essential service, demanded adjustments in the normal schedule and care for respiratory symptomatic patients(8). Considering that children and adults are exposed to contamination, but children are less likely to develop a severe form of the disease(9), care for this age group has become secondary, which stresses the need for care(8).

Thus, it is relevant to investigate the understanding of mothers about the aspects inherent to the milestones of this development during the COVID-19 pandemic, in order to promote and ensure child health. The guiding question for the study is "What is the perception of the mothers during the COVID-19 pandemic about child development from a childcare perspective? Therefore, the work is aimed at describing maternal knowledge about childcare during the COVID-19 pandemic.

METHOD

This is a descriptive, cross-sectional field research with a qualitative approach, carried out with mothers in two units, one located in the municipality of Borborema and the other in the municipality of Serra da Raiz, both in the state of Paraíba. Data were collected at the Eliane Flor da Silva Clementino dos Santos and Dr. José Weber by M. Lula Basic Family Health Units from August to September 2020. It should be noted that all research was guided by the COREQ guidelines.

The population consisted of 60 mothers, while the research sample was defined by convenience and established by the following inclusion criteria: mothers who follow up childcare for children aged 0-24 months within the Family Health Units in the municipalities of Borborema and Serra da Raiz, registered in the FHS coverage area and with cognitive and emotional conditions to attend the interview. The final sample consisted of 30 mothers, who met the inclusion criteria of the study.

It is worth noting that the data collection would be carried out at the FHS, however, due to the COVID-19 pandemic, the participants were selected at home. Thus, the researchers accessed the list of women assisted in the FHS and who had children in the last two years, contacted them by phone, and informed them about the purpose of the research. Visits were scheduled according to the availability of the mothers, and in compliance with all necessary protection and social distancing measures in the context of the COVID-19 pandemic.

For data collection, a non-validated, semi-structured questionnaire was used, from which the variables corresponding to the child's development were analyzed, as well as the mothers' perception of the topic. The instrument was guided by the following questions: Have you ever heard of childcare? Have you ever had a childcare appointment for your child? Do you know how important childcare is for your child's life? Do you know what procedures are performed in the childcare appointment? Do you know which professional is responsible for performing childcare in your unit?

Initially, a pilot test was carried out, considering the possibility of evaluating whether the items listed reflected the need for data collection, confirming, in fact, the usefulness of the aforementioned instrument. Thus, the variables related to the investigation of the mothers' perception of child development from a childcare perspective were considered, which led to the inclusion of this pilot in the study sample, given that there was no need to change the aforementioned instrument.

At the time of the interviews, the mothers were informed about the need to record the answers given using a sound recording instrument. Each interview lasted a minimum of 10 minutes and a maximum of 25 minutes, or until the mother asked for closure. The research was concluded based on the sufficiency of the results and saturation sample. There were no repeated interviews. To ensure the anonymity of mothers, each interviewee was represented by the name Mother and a number.

Data analysis was performed after the full transcription of the interviews recorded and organized on a Microsoft Excel spreadsheet, version 2016. For the statistical analysis, the percentage calculation was used to allow the quantitative characterization of the sample according to the pre-established criteria: age group, place of birth and investigation of childcare knowledge.

Qualitative data were analyzed after full transcription of the recorded interviews, organized and interpreted through Bardin's content analysis(10). The collections took place with the consent of the participants and, thus, the research obeyed the precepts of Resolution No. 466, 2012), of the Brazilian National Health Council, whose project was approved by the Research Ethical Committee (CAAE 31547020.0.0000.5176; Opinion No. 4.086.887) where all ethical precepts for research involving human beings were followed.

RESULT

The present study was carried out with 30 mothers of children aged between zero and 24 months, with emphasis on the Nursing Appointment for the child. Therefore, the data were categorized according to the variables and allowed for the characterization of the participants in terms of age and birthplace, according to Tables 1 and 2.

Table 1 – Characterization of mothers and children undergoing childcare in the city of Borborema (n=15). Borborema, PB, Brazil, 2020

*Children classified as Toddlers belonged to the age group of 1-2 years.

Source: Prepared by the authors, 2020.

Table 2 – Characterization of mothers and children undergoing childcare in the municipality of Serra da Raiz (n=15). Serra da Raiz, PB, Brazil, 2020

*Children classified as Toddlers belonged to the age group of 1-2 years.

Source: Prepared by the authors, 2020.

For this study, 4 categories were created: Mothers' knowledge about childcare; Childcare appointments in times of the COVID-19 pandemic; Surveillance of child development from the perspective of mothers; Mothers' knowledge about the assessment of infant developmental milestones.

Mothers' knowledge about childcare

The lack of knowledge of the mothers assisted at the Family Health Unit were notorious during the childcare appointment. The study found that of the 30 mothers, 20 reported having no knowledge of childcare.

I don't know very well (Mother 2).

More or less, I have many doubts about everything at this stage (Mother 6).

No, because I have never been to the appointment (Mother 5).

It is worth noting that, to collect data for this study, it was necessary to explain a little bit about childcare when the mothers reported being unaware of it. Then, it was possible to proceed with the study about the knowledge about childcare appointments.

Some mothers demonstrated they knew a lot about childcare, as shown in the following statements:

Yes, I know that both the nurse and the pediatrician assess and monitor the child (Mother 1).

In childcare appointments, growth, measurement, weight are assessed, and mothers receive guidance regarding hygiene and vaccination (Mother 21).

Yes, I saw the nurse and she said I had to follow each phase of my son's growth (Mother 24).

It is important because my child's growth and development will be assessed (Mother 15).

Childcare appointment during the covid-19 pandemic

Mothers are aware of attending childcare appointments, however, they reported that due to the COVID-19 pandemic they stopped taking their child.

Yes, I have attended the appointments several times, but I stopped in March (Mother 11).

Of the 30 mothers, eight reported that the child has not yet attended any appointments because of the pandemic.

No. Because of the pandemic, I thought it was risky to take my daughter (Mother 7).

No, lack of time and the pandemic (Mother 6).

We are in a pandemic (Mother 2).

Due to the pandemic scenario, a mother considers that the child should only attend appointments in case of illness or vaccination. This is against what the Ministry of Health recommends, since the child must attend appointments regardless of health status:

I only take my son to nursing appointments when he needs to be vaccinated. Then, the nurse takes the opportunity to weigh him and do everything at once. Other than that, I only take him if he is sick (Mother 15).

The low adherence to appointments during the pandemic period is worrisome, since monitoring children is essential to promote health, identify risk factors and diseases in a timely manner, prevent diseases, and provide a better quality of life for children so that they can be a healthy adult. In addition, it helps the development of children with comorbidity with a satisfactory standard for each situation.

Surveillance of child development from the perspective of mothers

When analyzing the samples of this study, about 24 mothers were aware of the procedures adopted in the appointment for developmental surveillance. Of these, 7 mentioned that the procedures are only anthropometric measurements:

Yes, anthropometric measurements (Mother 4).

I know, they are anthropometric measurements (Mother 9).

Another 11 mothers said that the procedures are related only to measurement and weight:

It is the following: the child is weighed and measured (Mother 28).

The nurse checks the child’s weight and height to see if they are reaching the expected measurements (Mother 27).

As far as I know, the child is measured, weighed (Mother 25).

Only four mothers out of 24 mentioned something related to child development:

Weight, head circumference, height, development monitoring (Mother 18).

Yes, weight, measurement and development evaluation (Mother 19).

[...] keeping head firm without support, smiling spontaneously and reproducing sound through the mouth (Mother 21).

And two mothers mentioned guidance and other procedures related to child development surveillance:

[...] guidelines on breastfeeding (Mother 25).

[...] follow the child's vaccination schedule (Mother 8).

Mothers' knowledge about the assessment of child developmental milestones

Of the 30 mothers, 27 are unaware of child development milestones. In addition, the data revealed in the research is noteworthy, highlighting the neglect of child development surveillance in primary health care, since most of these guidelines can be promoted by health professionals, even during home visits.

No. There's so much going on that I feel a tremendous lack of information, you know?! It's my first child and I know almost nothing (Mother 4).

The three mothers who reported knowledge about developmental milestones did not mention it completely, but it is clear that there is some understanding:

Sitting alone, crawling, saying a few words (Mother 17).

Yes, I follow these things on the Internet (Mother 19).

Yes, keeping head firm without support, smiling spontaneously and reproducing sound through the mouth (Mother 21).

It is worth noting that after the investigation about the mothers' knowledge, the participants received information about infant developmental milestones, as well as access to the instrument through the internet to encourage them to pay attention to their children.

DISCUSSION

In childcare, nursing appointment is directed to the mother-child binomial, and it is up to the nurse to take actions to provide better quality to the patient. Among these actions, we can include dialogue, since it is the nurse's duty to guide the child's caregiver on what will be done during the appointment, more specifically, on child development(11). Dialogue about childcare starts from prenatal care; however, the qualitative findings of this research point to a gap in care since more than half of the mothers demonstrated inadequate knowledge about childcare.

The mother’s limited knowledge about childcare has to do with several factors, such as unilateral dialogues, complicating the communication between health provider and caregiver, the non-performance of educational actions by the nurse(11), the relationship between childcare and anthropometric measures(12), as well as socioeconomic and school factors(13).

In a similar reality, a study carried out with 15 mothers in the city of Guarapuava-PR showed that more than half of them had limited knowledge of childcare and its importance for the child(12), which corroborates another study(13). These scientific data corroborate the research findings in which the majority's perception is limited regarding childcare understanding.

Despite the low quantity observed in the results of the study concerning mothers' knowledge about childcare, it is plausible to highlight that, like this one, other studies(14,15) reveal that there are mothers with adequate understanding, and this is satisfactory and consistent with the proposed guidelines in childcare. Even though numbers are low, there is persistence in improving quality.

In conclusion, one of the alternatives to fill this gap is to promote educational actions, by first gathering the multiprofessional team, then by creating a historical record of each family covered by the basic unit, as well as planning and implementing nursing interventions with the purpose of creating a bond with the family and offering a unique and efficient care for the child(3).

It is necessary to emphasize that some mothers in the qualitative findings of this study reported not knowing what childcare is because they did attend any appointment due to the COVID-19 pandemic. This finding is worrisome, since medical appointments are essential to promote health, prevent diseases, detect changes in a timely manner and provide a better quality of life for children, favoring their growth and development with good prospects for the adult life.

In this sense, the COVID-19 scenario becomes catastrophic for the health of children, delays the activities carried out in primary care and, consequently, the entire planning process designed and implemented for the biopsychosocial well-being of the child.

This fact corroborates the category Childcare appointments in times of the COVID-19 pandemic, showing that mothers failed to take their children to childcare appointments due to the pandemic scenario, which directly impacts child development.

In order to look for measures to recruit both children who need to have the first appointment and those who stopped attending, whether for administrative reasons of the FHS or for the caregiver's fear, cities in the country are adopting strategies to overcome this situation. In Florianópolis/SC - Brazil, teams are being instructed to proceed with an active search for children to attend their first childcare appointment(16). However, putting it into practice is challenging and not all places have a satisfactory response, showing weaknesses in this process(8).

It is worth noting that this difficult scenario permeates the global level. In Spain, there are delays in children vaccination because of the strictness of social distancing and this has drawn the attention of health providers, who demand active policies to summon children who are late in both immunization and childcare appointments(17).

The absence of the child in the childcare appointment in this COVID-19 pandemic causes disruption of care and this can influence the increase in morbidity, infant mortality and malnutrition, especially in developing or low-income countries(18). Furthermore, it also affects child development, bringing more negative consequences(19), such as deficit in nutritional status with micronutrient deficiency, dwarfism(20), impairment of children's learning, mental health, social development(19), among other skills that are monitored in the childcare consultation.

From a different perspective to child development, it is worth noting that the impacts of the COVID-19 pandemic severely affect the children. Research carried out in Kenya revealed an increased risk of child sexual abuse, domestic violence, neglect of care, a greater vulnerability in disabled children, increased teenage pregnancies, lack of access to primary health services, and a drop in children attending appointments(20).

The caregiver's resistance to take the infant to the health services motivated by fear, apprehension, and insecurity is alarming but very recurrent in times of pandemic. This finding corroborates a study conducted in all basic units of three medium-sized municipalities, one in the State of Paraná, one in the State of São Paulo, and another in the State of Minas Gerais, in which nurses point out family reluctance, together with fear. They also report that this may be due to information spread on social media, fake news and the news propagated in the community itself(8).

As for the mothers' perception of developmental surveillance, this research showed that 80% (24 mothers) knew what the procedures are; however, there is a limitation on the totality of the procedures used in the surveillance of child development.

Corroborating this result, research(14,15) show that the child's caregiver recognizes child development, its importance for the child, and the procedures performed. This can be associated with the mother's role, in which she recognizes herself as the person responsible for the child's well-being, and the imposition of society, which considers the mother's duty to provide care to the child(14).

Another aspect that allows mothers to have this knowledge is the bonding with the professional, given that the mother feels more comfortable in telling her anguish, doubts and joys(15). At the same time, the professional perceives the mother's non-verbal communication and listens to her, therefore establishing a comprehensive dialogue in which mothers are able to clear up their doubts(2).

However, a study with significant results reveals that the difficulties experienced by nurses on a daily basis directly affect the bond with the mother and the willingness to inform them. Consequently, many mothers cannot understand the importance of child development surveillance(11).

In the category “Mothers’ knowledge about the assessment of infant developmental milestones”, 80% (27 mothers) are not aware of the developmental milestones, which shows that, despite the statements in the previous category saying that they are aware of the procedures performed in the development surveillance, when asked about something deeper and more specific, many failed to report. In this aspect, poor knowledge or learning skills could be observed.

The qualitative findings of this research show that the limitation of knowledge depth on the developmental milestones is related to the lack of information or to fragmented communication. A study in five districts in Paraíba showed that nurses did not report in detail what was evaluated and sometimes they get confused. Others, when evaluating developmental milestones, are restricted to measurements of growth and a general assessment of the child, without even evaluating the risks for a developmental deficit(11).

It is worth mentioning that, to date, scientific articles with qualitative data in which mothers correctly narrate all infant developmental milestones have not been found. Therefore, it is important that health providers promote feedback techniques, dialogue with an accessible language, and help the mothers’ understanding.

This fact confirms the need for nurses to carry out educational actions, to inform mothers about child development, with an emphasis on developmental surveillance in the context of Integrated Care for Prevalent Childhood Illnesses (ICPCI) but, above all, the evaluation of milestones for each age group.

This research had as a limitation the fact that it was carried out at home, and as a result, the answers were short, the ideas were somewhat disconnected, and this made it impossible to deepen the topic.

CONCLUSION

The results of this work reveal weaknesses in the communication of professionals with mothers and a limitation of the mothers' knowledge regarding childcare and child development.

Most mothers do not understand what childcare encompasses, although they know that there are appointments that children need to attend. This is an alarming finding, because understanding the importance of taking children to an appointment has to do with understanding the essence of childcare.

The consequence of the lack of understanding and the situation of the COVID-19 pandemic led to the results of this research, in which mothers stopped taking their children to the nursing appointments, including those who had their children in the pandemic and, therefore, did not attend appointments in the Family Health Strategy. In this context, there is also a new organization of the service for the care of respiratory symptoms, which reinforces the fear of mothers to take their children to appointments under these circumstances, favoring a gap in comprehensive care and surveillance of the child's development.

As for the knowledge of child development, this scenario is worrisome since the complete infant development requires stimuli, which are guided by the family on a daily basis at home. In conclusion, these results can serve as a guide for further research. Other studies in different scenarios of the country on the perception of mothers in relation to child development are suggested to reveal the reality of different places regarding this topic, which may lead to other important evidence.

ACKNOWLEDGEMENTS

We thank the mothers who participated in the study.

CONFLICT OF INTEREST

The authors have declared that there is no conflict of interest.

FINANCIAL SUPPORT

CAPES - Process number: 88887.487273/2020-00

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Submission: 06/22/2021

Approved: 12/03/2021